HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 62 WILLOW RIDGE ROAD 5/5/2022 RECEIVED
N Commonwealth of Massachusetts
W City/Town of No. Andover MAY 0 5 2022
System Pumping Record �wr� )FNORTHANDOVER
iG^M
Form 4 HEr`,LTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on they he tab, ,S ..-K—!A )) I 1 G�\ �p
use only the tab � d J ICaC G
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
e elo it
Name
reneai
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 1000
1. Date of Pumping Da a 2. Quantity Pumped. Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes allo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. Syste ped By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
Signature of l4auler Date
Same day
Signature of Receiving Facility(or attach facility receipt) Date
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